Error traps in the perioperative care of children with chronic pain.

Pediatric patients with a history of chronic pain frequently have complex health needs that are challenging to meet in the perioperative period. Error traps are consequences or errors that are known to occur due to either gaps in knowledge or cognitive errors. Avoiding common error traps in these children can contribute to improved patient care and patient outcomes and overall better patient and family satisfaction. In patients with chronic pain, common errors during their perioperative care included as follows: failure to adequately prepare the patient and family; failure to incorporate past pain history and therapy into current treatment plans; failure to provide adequate multimodal analgesia; and failure to provide multidisciplinary and multimodal analgesia by incorporating other services such as mental health services and physical therapy. Cognitive errors may play a role in these error traps. Recognizing and avoiding them may improve and optimize pain care and outcome.

Novel utilization of strand-specific reverse transcription polymerase chain reaction in perioperative clinical decision making for SARS-CoV-2 polymerase chain reaction positive patients.

In order to prevent in-hospital transmission and potential complications related to SARS-CoV-2 in the perioperative patient, most healthcare institutions require preoperative testing for SARS-CoV-2 prior to proceeding with elective surgery. The Centers for Disease Control and Prevention (CDC) recommends a time and symptom-based duration of isolation for the presumed infectious period. The guidance to avoid retesting of asymptomatic patients in the 90 days following a positive reverse transcription polymerase chain reaction (RT-PCR) test is because of the possibility of detection of non-infectious viral shedding. When to reschedule asymptomatic patients who test RT-PCR positive for SARS-CoV-2 preoperatively is of considerable debate, both from the perspective of ensuring a patient's full preoperative fitness, as well as reducing the risk of viral transmission within the hospital. We describe the novel perioperative use of a strand-specific assay to detect minus strand ribonucleic acid (RNA) in a clinical decision-making algorithm to determine optimal timing of elective surgery after a patient tests RT-PCR positive for SARS-CoV-2. This is the first description in the literature of an attempt to further stratify patients who repeatedly test positive for SARS-CoV-2 into infectious versus non-infectious for perioperative planning.

Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know.

In 2018, 29 states allow the use of medicinal marijuana. In these states, minors, with parental permission, are granted access. Use has increased in some states, although there remains a paucity of clear evidence regarding usefulness and dosing. There are 2 Food and Drug Administration-approved synthetic derivatives. One purified compound was just approved by the Food and Drug Administration, and another is undergoing Food and Drug Administration review. This article will review the literature regarding the use of each of these compounds in the literature, with particular attention to data in children. The history, known pharmacology, data from nonmedicinal use, current evidence, and anesthetic considerations will be described.

Postdural Puncture Headaches in Pediatric Patients: A Review of Options When Repeated Epidural Blood Patches Do Not Work.

We present the case of an adolescent with refractory postdural puncture headache (PDPH), whose symptoms resolved with a sphenopalatine ganglion (SPG) nerve block using a J-tip style catheter. Our patient was treated with multiple modalities, including conservative and medical management, multiple epidural blood patches, and different nerve blocks. We discussed different treatments for the PDPH, why each modality did not work, and why our SPG block with a J-tip catheter possibly provided a better sympathetic block in a patient with intractable PDPH for two weeks.

Review of Ultrasound-Guided Procedures in the Management of Chronic Pain.

This article summarizes clinical expert recommendations and findings for the application of ultrasound-guided procedures in chronic pain management. Data on analgesic outcomes and adverse effects were collected and analyzed and are reported in this narrative review. Ultrasound guidance offers opportunities for the treatment of pain, with focus in this article on greater occipital nerve, trigeminal nerves, sphenopalatine ganglion, stellate ganglion, suprascapular nerve, median nerve, radial nerve, ulnar nerve, transverse abdominal plane block, quadratus lumborum, rectus sheath, anterior cutaneous abdominal nerves, pectoralis and serratus plane, erector spinae plane, illioinguinal/iliohypogastric/genitofemoral nerve, lateral femoral cutaneous nerve, genicular nerve, and foot and ankle nerves.

Technical note: Evaluation of sampling methods for methane concentration from in vitro fermentation.

The objectives of this multipart study were 1) to assess the efficacy of sampling methods of methane concentration ([CH4]) of headspace gas produced during in vitro gas production (IVGP) fermentation, 2) to verify whether headspace [CH4] sampled from an exetainer has the same [CH4] as the headspace of IVGP bottles, 3) to measure relative humidity (RH) within an IVGP bottle, and 4) to compare [CH4] on a dry-gas (DG) basis when accounting for water vapor pressure (Pw). The original IVGP protocol recommends placing bottles on ice (0 °C) for 30 min to stop fermentation (ICE). A laboratory protocol recommends placing the bottles in the refrigerator (4 to 6 °C) to slow fermentation for 48 h and subsequently allowing the bottles to return to ambient temperature before sampling (FRIDGE). This study evaluated the previous methods against a direct sampling of the headspace gas after incubation (DIRECT). Rumen inoculum from four rumen-cannulated beef steers was combined and homogenized before incubating the fermentable substrate of ground alfalfa hay. After 48 h of IVGP incubation, each bottle was randomly assigned to a treatment protocol. The pressure (P), volume (V), and temperature (T) of headspace gas in each bottle were recorded. Headspace gas was then thoroughly mixed, and 12 mL gas was removed into an evacuated exetainer for [CH4] sampling via gas chromatography (EXET; Objective 1). Eight bottles from ICE and FRIDGE were randomly selected to follow EXET, whereas the remaining bottles had [CH4] directly measured from their headspace (BOTT; Objective 2). Five diets of differing feed composition and nutrient densities were used with a blank to test the RH of the IVGP slurry (Objective 3). Using RH, [CH4] was transformed to a DG basis to account for Pw (Objective 4). Statistical analysis was completed using a random coefficients model. There were no differences between EXET and BOTT (P = 0.28). The RH of the IVGP slurry was 100% (P = 1.00), confirming that IVGP gas is saturated with water vapor. The P, V, and T differed among treatments (P < 0.01). The [CH4] of DIRECT, ICE, and FRIDGE were different (P < 0.01). Dry-gas P, V, and [CH4] differed among treatments (P < 0.01). As the methods differ in their assessment of [CH4], there is no clear recommendation. Instead, to present a more accurate [CH4], P, V, and T should be measured when sampling headspace gas and equations presented should be used to remove volume inflation due to water vapor and present [CH4] on a DG basis.

Greenhouse gas emissions (GHG) from ruminant production equate to 81% of total global livestock supply chain emissions, with 51% originating from beef cattle production. Traditional in vivo estimation methods of methane (CH4), a highly scrutinized greenhouse gas, are timely and costly. In vitro gas production (IVGP) methods can accurately describe CH4 emission patterns from the rumen but tend to overestimate quantities. Additionally, in vivo estimation methods present CH4 on a dry-gas basis, whereas in vitro do not. In vitro methods utilize a gas chromatography machine to estimate CH4. Laboratory constraints can impose deviations to a strict IVGP protocol. This multi-objective study evaluates three treatment methods of IVGP bottles to understand whether discrepancies exist in CH4 estimation when deviating from the published protocol. To estimate CH4 from IVGP more accurately and provide a more comparable number to in vivo methods, this study also evaluates environmental conditions within an IVGP bottle to formulate a system of equations to calculate CH4 on a dry-gas basis. This study found that the treatment method of the IVGP bottle had an impact on CH4 estimation, and the developed equations should be utilized to produce more comparable estimates.

Effect of live yeast supplementation on energy partitioning and ruminal fermentation characteristics of steers fed a grower-type diet in heat-stress conditions.

The objective of this trial was to determine the influence of live yeast supplementation (LY), environmental condition (ENV), and their interaction (TRT) on energy partitioning, nitrogen metabolism, and ruminal fermentation dynamics of steers receiving a grower-type diet. The effects of LY and ENV were investigated using a 2 × 2 crossover design that spanned five periods. Eight Angus-crossbred steers were randomly split into pairs and housed in four outdoor pens outfitted with an individualized feeding system. Animals were limit-fed a grower diet (DIET) at 1.2% shrunk body weight (SBW) with no live yeast supplementation (NOY) or a grower diet top-dressed with 10 g LY/d for 14 d (1.2 × 1012 CFU/d). On days 13 and 14, animals were subjected to one of two ENV conditions, thermoneutral (TN; 18.4 ± 1.1 °C, 57.6 ± 2.8% relative humidity [RH]) or heat stress (HS; 33.8 ± 0.6 °C, 55.7 ± 2.7% RH), in two side-by-side, single-stall open-circuit, indirect respiration calorimetry chambers. Data were analyzed using a random coefficients model. Carryover effects were examined and removed from the model if not significant. Gross (GE), digestible, metabolizable, heat, and retained energies were not influenced by DIET, ENV, or TRT (P ≥ 0.202). Gaseous energy, as a percentage of GE, tended to increase during HS (P = 0.097). The only carryover effect in the study was for oxygen consumption (P = 0.031), which could be attributed to the tendency of NOY (P = 0.068) to have greater oxygen consumption. DIET, ENV, or TRT (P ≥ 0.154) had no effects on total animal methane or carbon dioxide emissions. Similarly, DIET, ENV, or TRT (P ≥ 0.157) did not affect ruminal pH, redox, protozoa enumeration, ruminal ammonia concentrations, and acetate-to-propionate ratio. Propionate concentrations were the greatest in animals in TN conditions receiving LY (P = 0.034) compared to the other TRT. This effect is mirrored by TN-LY tending to have greater acetate concentrations (P = 0.076) and total VFA concentrations (P = 0.065). Butyrate concentrations tended to be greater for animals fed LY (P = 0.09). There was a tendency for LY to have elevated numbers of Fusobacterium necrophorum (P = 0.053). Although this study lacked effects of LY on energy partitioning, nitrogen metabolism, and some ruminal parameters during HS, further research should be completed to understand if LY is a plausible mitigation technique to enhance beef animals' performance in tropical and sub-tropical regions of the world.

About 70% of global beef production is located in tropical and sub-tropical regions. With elevated temperatures and significant humidity, these regions impose heat stress on beef animals. Heat stress is the main antagonist to ruminant production as it decreases dry matter intake and digestion and increases energy expenditure due to the animal's need for thermoregulation. Supplementation of live yeast products has proven efficacious at improving ruminal fermentation dynamics. This study sets out to determine if live yeast supplementation to animals in heat stress conditions can positively affect energy partitioning, nitrogen metabolism, and ruminal parameters. Additionally, this study models the ruminal performance after exposure to heat stress or live yeast supplementation. This study identified several interesting in vitro dynamics of previously stressed- or supplemented rumen fluid. Although there were a lack of effects for live yeast supplementation on energy partitioning, nitrogen metabolism, and some ruminal parameters during heat stress, further research should be completed in order to understand if live yeast supplementation is a plausible mitigation technique to enhance the performance of beef animals reared in tropical and sub-tropical regions of the world.

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

BACKGROUND: The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force. METHODS: Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient's arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range). RESULTS: 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30). CONCLUSIONS: This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

Administering an appeasing substance to beef calves at weaning to optimize productive and health responses during a 42-d preconditioning program.

This experiment evaluated the impacts of administering a bovine appeasing substance (BAS) to beef calves at weaning on their performance, physiological responses, and behavior during a 42-d preconditioning program. Eighty calves (40 heifers and 40 steers; 90% British × 10% Nellore) were weaned at 233 ± 2 d of age (day 0); ranked by sex, weaning age, and body weight (BW); and assigned to receive BAS (IRSEA Group, Quartier Salignan, France; n = 40) or placebo (diethylene glycol monoethyl ether; CON; n = 40). Treatments (5 mL) were topically applied to the nuchal skin area of each animal following dam separation. Within treatment, calves were allocated to one of eight drylot pens (four pens per treatment; pen being the experimental unit) and received a free-choice total mixed ration (TMR) from day 0 to 42, intake of which was assessed daily. Live behavior observations were conducted on days 1, 2, 4, 8, 16, and 32. Temperament was assessed and blood samples were collected via jugular venipuncture on days -21, 0, 3, 7, 14, 28, and 42. Hair samples were collected from the tail switch on days 0, 14, 28, and 42. Calves were vaccinated against bovine respiratory disease viruses on days -21 and 0. Average daily gain from day 0 to 42 did not differ between treatments (P = 0.57) but was greater (P = 0.05) in BAS vs. CON calves from day 0 to 28. Intake of TMR was greater (P = 0.05) during the first week for BAS vs. CON calves (treatment × week; P = 0.08). The mean proportion of calves feeding simultaneously and performance of social and play behaviors were greater (P ≤ 0.05) for BAS vs. CON calves. Escape attempts were greater (P < 0.01) for BAS vs. CON calves on day 1 (treatment × day; P = 0.03). Exit velocity was greater (P = 0.04) for CON vs. BAS calves on day 14 and tended (P = 0.10) to be greater for CON vs. BAS calves on day 7 (treatment × day; P = 0.03). Mean plasma concentrations of haptoglobin were greater (P = 0.02) in CON vs. BAS calves. Hair cortisol concentrations were greater (P = 0.05) in CON vs. BAS calves on day 14 (treatment × day; P = 0.03). Mean serum concentrations of antibodies against bovine viral diarrhea virus were greater (P = 0.02) in BAS vs. CON calves. Collectively, BAS administration to beef calves at weaning alleviated stress-induced physiological reactions, improved temperament evaluated via chute exit velocity, enhanced humoral immunity acquired from vaccination, and appeared to have accelerated adaptation to novel management scheme and environment.

Complete Genome Sequence of Escherichia coli Myophage Mansfield.

Mansfield is a PB1-like Escherichia bacteriophage with a 68,120-bp genome and a predicted 3,673-bp direct terminal repeat. This myophage encodes 105 proteins, for which 32 functions were predicted.

Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids.

Opioid therapy is the cornerstone of treatment for acute procedural and postoperative pain and is regularly prescribed for severe and debilitating chronic pain conditions. Although beneficial for many patients, opioid therapy may have side effects, limited efficacy, and potential negative outcomes. Multidisciplinary pain management treatments incorporating pharmacological and integrative non-pharmacological therapies have been shown to be effective in acute and chronic pain management for pediatric populations. A multidisciplinary approach can also benefit psychological functioning and quality of life, and may have the potential to reduce reliance on opioids. The aims of this paper are to: (1) provide a brief overview of a multidisciplinary pain management approach for pediatric patients with acute and chronic pain, (2) highlight the mechanisms of action and evidence base of commonly utilized integrative non-pharmacological therapies in pediatric multidisciplinary pain management, and (3) explore the opioid sparing effects of multidisciplinary treatment for pediatric pain.

Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use.

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.